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FOR OFFICE USE: FOR OFFICE USE: i APPLICATION FOR SANITATION PERMIT (Co lete -im Triplicate) 6715 Permit No.............-_...__- •------------------ ....................... Date - .... This Permit Expires 1 Year From Date Issued Application is hereby made to.the Son Joaquin Local Health District for a-permit to construct and install the work herein described. This apptication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION.--O.. ------.CENSUS TRACT................................ I Owner's Name.... .. ..... --- .......- ..-- Ph one I . ... Cit �J � : Address---- Y �-`5 ----------------- iP = Contractor's Name....__ License Phone r . -- -- .. . # Installation will serve: esidence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other................ ..................... I Number of living units:..._..'......_.Number of bedroo s: Vrb eGrinder_::_-..-_'.'tot Size` . .....� .................. .. ! Water Supply: Public System and name........----••--- �,�f� ------------------------------------•- ------.Private ❑ Character of soil to a depth of 3 feet; ' Sand ❑ Silt 0 Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan - t Aclob`e Fill Material.. .-- _.If es`t a--------------------------- ---- P ❑. t .� ❑. Y Yp f (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must'be placed on reverse side.) li NEW INSTALLATION: (No septic tank or seepage pit permitted if public sZer is available within 200 feet,j PACKAGE TREATMENT [ ] SEPTIC TANK [ ] f Size..... ...-- -�.- Liquid Depth.-- -- ----------- Capacity. -p(- LJ-!/.-Type- ...Matarial_- _ -- ------...No: Compartments---.-. ... ................... -•--• -- � --- --- Distance to nearest: Well.-.- Fo kdation.......... . .............Prop. Line------...--......._-...... 1 LEACHING LINE [ ] Na. of Lines - _�------------- Length of each line...... ._..._._ To al Length .. .._ ----------- '13-113 pe Filter Material._ Depth Filter Material. ................. ...... .......... Distance to nearest: Well_..___........... ........ oundatio roperty Line_.._.-.___-----__- -------------- SEEPAGE PIT [ ] Depth---��.0__Diameter....(._ .....Number......... . ...... ............ Rock Filled Yes No WaterTable Depth------------------------------- -------------------------Rock Size . .. ........................ Distance to nearest: Well.................... ..Foundation- o Line----------_------ . + REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- ---------------Date----...------......--------.-.--.---.---.------1 Septic Tank (Specify Requirements].................. .. ------------,................................. Disposal Field (Specify Requirements)---------------- -----_-----------------.- (Draw existing and required addition on reverse side) ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents a signature certifies the following: fp "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as k to become subject to Workman's Comp ation laws of Colifornia." q Signed /l -- --- - ------ ---- wear BY-----.... Title.-- --- ------------------- - -------- -------------------- --- (If o han wner FDEPAR MENT USE ONLY APPLICATION ACCEPTED BY------ ... ...------ a'`. _... . - DATE ........ . ---`�`�. -� 7 ............ DIVISION OF LAND NUMBER...... ........ . DATE....---...--------- ... - { ------------ ------------- ----------- ------- - ---------------------------- ADDITIONAL COMMENTS................. . . --.-.--..-- ............... --------------- ............................................................. .............. ---------------------.....---...---...--------........... --------------------------------- - --------------- ----- --•-- ------•- --- --------- ---------------•--------------------....- -------------------._.... --------•--------- •• ..--- Final Inspection by:..... CJ1,�- - _ Date- EH ate ----- - _as_ .- -.-. -- - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT MS 21677 REV. 7/76 3M k